Migraine and Aura

Migraine is a common and disabling condition reported in approximately 12% of the population. In the Global Burden of Disease Study by the World Health Organization, updated in 2013, migraine was found to be the sixth highest cause worldwide of years lost due to disability. Migraine is a genetic, neurological disease. It is divided into two major subtypes: migraine without aura and migraine with aura. Migraine with aura occurs in 25-30% of migraineurs. Few people have the aura phase with every migraine attack. Thus, it’s quite common to be diagnosed with both migraine with aura and migraine without aura.

There are many different types of migraine with aura including:

  • Migraine with typical aura; with headache or without headache
  • Migraine with brainstem aura
  • Hemiplegic migraine
  • Retinal migraine

The term “aura” denotes recurrent attacks of neurologic symptoms that can include visual, sensory, speech, motor or other central nervous symptoms. The neurologic symptoms generally last only minutes in duration and should be fully reversible. Often the symptoms are unilateral, meaning that they occur on only one side of the body or occur on one side of the visual field. The aura is generally followed by a headache. In some migraine attacks, however, migraineurs may experience aura but no headache. This has been previously called “silent migraine,” or “acephalgic migraine”. This can become more common as people get older.

Diagnosis

People with new or never-evaluated aura should be carefully assessed by their doctor for an underlying cause, as aura can mimic other conditions such as transient ischemic attack, stroke or seizures. It is also important to be assessed so as to confirm what sub-type of aura you have as different aura types have different treatment recommendations.

Please refer to the International Classification of Headache Disorders 3rd edition (beta version) website for more information on the criteria used to diagnosis migraine with aura: https://www.ichd-3.org/1-migraine/1-2-migraine-with-aura/

The Phases of Migraine with Aura

In migraine with aura, a migraine attack can consist of a combination of these phases:

  1. Premonitory
  2. Aura
  3. Headache
  4. Postdrome

The Premonitory Phase

The premonitory phase (sometimes called preheadache or prodrome phase) may be experienced hours or even days before a migraine attack. The premonitory phase may be considered to be the migraineur’s “yellow light,” a warning that a migraine is imminent. For migraineurs who experience premonitory symptoms, it makes a solid case for keeping a migraine diary and being aware of one’s body.

Potential symptoms of the premonitory phase are:

  • Food cravings
  • Constipation or diarrhea
  • Mood changes — depression, irritability, etc.
  • Muscle stiffness, especially in the neck
  • Fatigue
  • Increased frequency of urination
  • Yawning
  • Sensitivity to light
  • Sensitivity to sound

The Aura Phase

The symptoms and effects of aura vary widely. Some can be quite terrifying, especially when experienced for the first time. Some of the visual distortions can be exotic and bizarre. It’s interesting to note that migraine aura symptoms are thought to have influenced some famous pieces of art and literary works. One of the better known is Lewis Carroll’s “Alice in Wonderland.”

Typical auras can have a wide range of symptoms, including:

  • Visual – Examples include sparkles or zigzag lights in the vision that may move or get larger. Generally on only one side of your vision. If you alternate eyes, the vision changes are seen through either eye but may appear more prominent through one eye or the other.
  • Sensory – Examples include numbness or tingling that travels up one arm to one side of the face.
  • Speech/language symptoms – Examples include trouble producing words even though you know what you want to say or trouble understanding what people are saying.

Each symptom is fully reversible and usually only lasts up to 60 minutes each. There should not be any motor (weakness or paralysis) or retinal (vision loss or changes in one eye only) symptoms with typical aura.

The Headache Phase

The pain of the headache can range from mild to severe. It can be so intense that it is difficult to comprehend by those who have not experienced it. Characteristics of the headache phase may include:

  • Headache pain that is unilateral (on one side). This pain can shift to the other side or become bilateral.
  • Although migraine pain can occur at any time of day, it is not uncommon for migraineurs to be awakened by the pain.
  • The headache usually lasts from 4 to 72 hours. In children it can last 2 hours.
  • The pain is worsened by physical activity.
  • The pain can be accompanied by:
    • Phonophobia—increased sensitivity to sound.
    • Photophobia—increased sensitivity to light.
    • Osmophobia—increased sensitivity to odors.
    • Nausea and vomiting.

The Postdrome Phase

Once the headache is over, the migraine attack may or may not be over. The postdrome (sometimes called postheadache) follows immediately afterward. The majority of migraineurs take hours to fully recover; some take days. Many people describe postdrome as feeling “like a zombie” or “hung-over.” These feelings are often attributed to medications taken to treat the migraine, but may well be caused by the migraine itself. The symptoms of prodrome may include:

  • Lowered mood levels, especially depression
  • Poor feelings of well-being
  • Fatigue
  • Poor concentration and comprehension
  • Lowered intellect levels

Treatment

Treatment of migraine with aura should consist of:

  • Acute medications for use at onset of a headache attack to try to break it. Limitation on number of uses of acute medications is important to try to avoid medication overuse and reduce risk of medication overuse headache. Triptans are migraine specific acute medications. They are contraindicated in the setting of hemiplegic migraine, migraine with brainstem aura and retinal migraine.
  • Preventive medication to help reduce the frequency and severity of headache attacks. Preventive medications should be considered based on patient preference, when migraines are occurring more than once per week, the migraines are interfering with routine activities, and acute medications are ineffective or contraindicated.
  • Non-medication preventive treatments including biofeedback, cognitive behavioral therapy
  • Addressing risk factors such as depression, anxiety, snoring, obesity, etc.

Migraine with aura slightly increases the risk of having a stroke so women who have migraine with aura need to think carefully about the potential risks associated with birth control pills that contain estrogen or hormone replacement therapy.

Summary

Migraine is a common and disabling neurolgic condition. About 25-30% of migraineurs experience migraine with aura. Typical aura consists of fully reversible neurologic symptoms, including visual, sensory and speech, that typically last 5-60 minutes. Anyone presenting with new or never-evaluated aura-like symptoms should be assessed by their doctor to ensure that they do not have any underlying condition that may mimic aura.

Resources:

The International Headache Society. https://www.ichd-3.org/1-migraine/1-2-migraine-with-aura/

Cutrer FM, Huerter K. Migraine aura. Neurologist 2007; 13:118.